Provider Demographics
NPI:1063694479
Name:CALIFORNIA STATE POLYTECHNIC UNIVERSITY
Entity type:Organization
Organization Name:CALIFORNIA STATE POLYTECHNIC UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAY
Authorized Official - Middle Name:
Authorized Official - Last Name:VIERRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-869-2760
Mailing Address - Street 1:3801 W TEMPLE AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-2557
Mailing Address - Country:US
Mailing Address - Phone:909-869-4000
Mailing Address - Fax:
Practice Address - Street 1:3801 W TEMPLE AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-2557
Practice Address - Country:US
Practice Address - Phone:909-869-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306630261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health